Docs onboard?

Should helicopter air ambulance services be paramedic or physician-led, and which is the safest and most practical? The global HEMS community has differing opinions, as Lucie Wood finds out

The Northern Ireland (NI) health authorities and Air Ambulance Northern Ireland (AANI) made headlines in the local and industry press recently. The two organisations have been working together to set up HEMS coverage for Northern Ireland. The reason that this was particularly newsworthy was that in the interim period before the service was approved by NI’s Minister for Health Michelle O’Neill, there was debate about the necessity of flying with a doctor onboard. O’Neill received an open letter signed by 25 pre-hospital specialists from HEMS organisations around the world who expressed their concern that ‘NI paramedic HEMS experience in this high acuity and high consequence environment is limited’, and who feared that ‘the Service will not be capable of providing the best life-saving care possible to the people of N.Ireland from the outset if a doctor is not onboard the helicopter’.

In the event, Northern Ireland’s new HEMS will have two EC135 helicopters and pilots supplied by Babcock Mission Critical Services, while medical staff and equipment are provided and funded by NI’s Health and Social Care Services, and the service will have doctors onboard. But would the service have been short-changed by a paramedic model? And is it true that most paramedic-led services in the UK, Europe, Eastern Europe, Asia, much of Australasia are moving towards a physician onboard as standard for HEMS, as the letter stated?

Tim Rogerson, doctor for the Emergency Medical Retrieval and Transfer Service (EMRTS) in Wales, UK, was a signee of the letter calling for a doctor-led HEMS. He says that doctors and paramedics bring different and complimentary skills and knowledge. “A doctor-paramedic model as part of a pre-hospital critical care team is delivered in most UK pre-hospital services, and, if not, is in the planning stages. It is the standard of care provided by many HEMS providers across the world. The addition of a doctor to the team allows full provision of life and limb saving interventions which would not be possible with a purely paramedic model in the UK.”

Rogerson, who has worked with HEMS in the UK and Sydney in Australia, says: “The addition of a physician in a pre-hospital critical care team allows the full provision of life and limb-saving interventions in the pre-hospital environment. This includes blood and clotting products, general anaesthesia, pre-hospital amputations and clam-shell thoracotomy. Some services are adding advanced resuscitation techniques to this including REBOA [resuscitative endovascular balloon occlusion of the aorta]. With these additional interventions, the HEMS is becoming a delivery tool for the pre-hospital critical care team, who can deliver many of the interventions available in the resus room at the scene.”

But should having a doctor onboard HEMS be seen as a gold standard rather than a necessity? Chief executive of Wiltshire Air Ambulance (WAA) David Philpott, who is responsible for a paramedic-led service funded solely by charitable donations, thinks so: “It is the platinum standard and very expensive. If the NHS funded doctors on helicopters, one would be a fool not to want them. However, doctors don’t come cheap – costs ranging from £500 to £1,000 a shift.” As with many services in the UK, WAA has access to paramedics seconded from the state-funded National Health Service (six of its 11 paramedics are funded by South Western Ambulance Service).

Philpott continued: “Charitably funded air ambulances have a duty to their donors to ensure that donations are being properly spent. A few air ambulance charities (including Wiltshire) have a small cohort of doctors who work onboard the helicopter from time to time as unpaid volunteers.” Using doctors onboard could also damage the reputation of Wiltshire Air Ambulance, explains Philpott, if allegations of clinicians profiteering from charities were ever upheld.

As for the medical limitations posed by a paramedic-only service, there are some impediments, Philpott says, but they are rarely seen. This is backed by NHS tasking data, he said: “From the data, we see that in 2016, Wiltshire Air Ambulance with a [critical care paramedic]/paramedic team were deployed to traumas on 361 occasions, whereas another air ambulance in the region using the physician/paramedic model was deployed to 260.”

Rick Sherlock, president and CEO of the Association of Air Medical Services (AAMS) in the US, explains that fielding a physician onboard every HEMS flight is not pragmatic or feasible in every situation in the US. “As an example, the state of Minnesota has about six million people and is roughly two-thirds the size of Germany, which has about 81 million people,” he says. “The US has vast distances and many areas with low population densities. There are not enough doctors to have one onboard every helicopter or critical care ground ambulance transport under these circumstances.”

Should HEMS be doctor-led ideally, though? “Actually, HEMS services in the US are ‘doctor-led’,” Sherlock explains, “the clinical guidance is simply done remotely during transport of the patient. Medical control is always available and involved for any issues that are encountered by the crews when caring for the patient on the flight.” He goes on: “AAMS does not believe that there must be a doctor as part of the flight crew, but does believe that programmes need doctor-led medical direction and oversight. The most common HEMS crew in the US consists of a nurse and a paramedic. Only about five per cent of US programmes have a physician onboard. Given the scope-of-practice for nurses and paramedics, proper training and with good medical oversight, it has not been shown that a crew with a physician has better outcomes.”

Eileen Frazer, executive director of the accreditation body Commission on Accreditation of Medical Transport Systems (CAMTS) based in South Carolina, US, refers to a study backing this: “The University of Wisconsin (physician-led flight teams) and Mayo Medical Transport (nurse/paramedic teams) compared transports events and hospital outcomes of 398 STEMI [ST-Elevation Myocardial Infarction] patients. This study found that both had zero-per-cent deaths in transport, and no statistical difference in the rate of in-hospital deaths or length of stay. There were higher rates of nitro-glycerine and opioid administrations in the nurse-paramedic teams, which could have led to a higher rate of adjusted in-hospital events. But more study is needed.”

When looking at HEMS models in the US and the UK, it’s important to note the differing training and background of the professions. “In the US, nurses are more highly trained and experienced to conduct interfacility transports than paramedics and therefore, critical care nurses are found on most critical care teams,” Frazer explains. “Physicians, unless they are in an Emergency Department Residency (and air medical transports are part of their rotations) are rarely part of the team with nurses operating under medical protocols from the medical director. We encounter physician-led teams in most other parts of the world where the culture has developed with physician/ paramedic teams and where nurses may not have the same level or scope of practice as paramedics.”

Sherlock of AAMS says the two disciplines of nursing and paramedicine are mutually supportive by their skill sets and experience. “For example, paramedics often have extensive experience with scene calls, while nurses have ICU experience for inter-facility transports. Here in the US, there are differences in state law as far as scope of practice for each discipline. In some states, medics can intubate and nurses cannot, while it is the reverse in other states. Thus, the nurse and paramedic are mutually supportive in taking care of the patient.” Procedures onboard that would not be possible without a doctor would include a REBOA, lateral canthotomy, and a left lateral thoracotomy.

But the letter to O’Neill said that without a doctor onboard, HEMS at times becomes unsafe. It said: “Placing a combative, agitated, head injured or bleeding patient in a helicopter without a general anaesthetic is unsafe, both to the patient and the crew.” But Sherlock disagrees that you need a physician in this instance, in the US at least. “It doesn’t matter who is onboard in this particular situation. A combative, agitated patient would never be placed inside the aircraft without first being sedated with paralytics for rapid sequence intubation, as well as agents like ketamine for agitation. This has become standard of pre-hospital care in the US and it does not require a physician to administer the drugs.”

In conclusion, context is all in this debate. The funding model of the service, which country the HEMS is operating in, or even which region – rural or metropolitan – will in part determine the kind of service is safest and most practical. While Sherlock, operating in the US, sees no reason to move to a physician onboard every HEMS flight (“Our nurses and paramedics provide excellent patient care. HEMS providers in the US do have strong medical oversight, including intense continuous quality improvement and training overseen by the medical director”), in the UK Philpott of WAA appreciates the benefits of a physician but funding precludes it: “Yes, this is the direction [HEMS services are moving towards] and if funded by the NHS we would embrace it. However, we are already funding 50 per cent of our paramedic costs because the NHS has a budget crisis, so I think government-funded doctors is therefore unlikely.”

As for the Northern Ireland HEMS service, again it must be viewed in context, Philpott says: “The geography of Northern Ireland will dictate which clinical model is preferable. With tens of thousands of people living at great distance from A&E services, there may be compelling reasons to use the physician onboard the aircraft to guarantee equity of health provision.” △